Affidavit of No Insurance

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STATE OF NEW JERSEY    )                      
                                                ) SS:                AFFIDAVIT OF NO INSURANCE
COUNTY OF                         )

            I,                                  , of full age, being duly sworn according to law, upon my oath, deposes and says:

1. On _________________, I was involved in an automobile accident.
2. On aforesaid date, I lived at:
3. On aforesaid date, I did not own an automobile nor did I reside with anyone who owned an automobile nor did I have a policy of automobile insurance to cover me for this accident.

I certify that the above is true. I am aware that if any of the foregoing is willfully false, I am subject to punishment.

Sworn and Subscribed to before me on

this           day of                              ,200.

___________________________________

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